[Chainsaw lacerations of the face].

This is a case report of two patients, who had accidental self-inflicted chainsaw lacerations of the face. The injuries were remarkably similar with jagged soft tissue lacerations and soft tissue parts of questionable vitality. These cases and their treatment are presented to show examples of the handling of soft tissue injuries of the face in an emergency department setting and to show, that very conservative debridement of these injuries is the recommended approach.

[Lipoatrophy after insulin injections can be treated with lipofilling].

Lipoatrophy is a known, albeit rare, side effect of insulin injections. We describe a case concerning a 17-year-old woman with insulin-dependent diabetes, who was treated with an insulin pump. In the areas surrounding the injection point subcutaneous lipoatrophy occurred. Such lipoatrophy is of cosmetic importance, and it may incur glycaemic imbalance due to altered and unpredictable absorption of insulin in the atrophied areas. With no spontaneous regeneration of the atrophied areas observed the patient was successfully treated with lipofilling in the atrophied areas.

[Inverted nipples].

Inverted nipples is an anatomical variation which can be uni- or bilateral, congenital or acquired. The degree of inversion can vary from slight to severe. Treatment can be surgical or non-surgical and should depend on the degree of functional problems. Non-surgical treatment can be beneficial, does not risk affecting sensibility, spares the lactiferous ducts, and therefore does not risk any interference with breast-feeding. Surgical options should only be considered when non-surgical treatment is insufficient.

Measurement of breast volume is a useful supplement to select candidates for surgical breast reduction.

INTRODUCTION: The indication for breast reduction in a public welfare or an insurance paid setting depends on the severity of the subjective symptoms and the clinical evaluation. The purpose of this study was to evaluate the use of breast volume as an objective criterion to establish the indication for breast reduction surgery, thus establishing a standard decision basis that can be shared by surgeons and departments to secure patients fair and equal treatment opportunities. MATERIAL AND METHODS: A total of 427 patients who were referred to three Danish public hospitals with breast hypertrophy in the period from January 2007 to March 2011 were included prospectively in the study. The patients' subjective complaints, height, weight and standard breast measurements were registered as well as the decision for or against surgery. Breast volume was measured using transparent plastic cups. RESULTS: Cut-off values for breast volume were calculated based on whether or not the patients were offered reduction surgery. Most patients (93%) with a breast volume below 800 cc were not offered surgery, while most with a volume exceeding 900 cc were offered surgery (94%). In the grey zone between 800 and 900 cc, the indication seemed to be less clear-cut, and additional parameters need to be included. CONCLUSION: Breast volume can be used as an objective criterion in addition to the presently used criteria. Breast volume can easily be measured and has become appreciated by plastic surgeons dealing with patients with breast hypertrophy as a tool which facilitates their decision-making and patients' acceptance of the decisions made. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[A primary adenomucinous carcinoma on the upper eyelid]. / Primært adenomukøst karcinom på øjenlåget.

In this case we present a 70-year-old male with a primary adenomucinous carcinoma (PKMK) on the upper eyelid. Radical surgery or radiotherapy could not be implemented, due to aggressive behaviour caused by dementia. PKMK is a rare tumour with 228 described cases. Clinically the tumour can be misdiagnosed as benign, but has the potential to lymph node-, regional- and remote metastasis. Histologically it may be difficult to distinguish from adenocarcinomas (breast-, colorectal-, ovarian-, prostate- and lung cancer). The treatment is surgical with radical excision by Mohs' procedure (abroad) or guided by intraoperative biopsies (Denmark).

[PET scanning for malignant melanoma and positive sentinel node diagnostics]. / PET-skanning ved malignt melanom og positiv sentinel node.

INTRODUCTION: To illuminate the value of using positron emission tomography (PET) scan as a clinical routine screening procedure for detecting subclinical metastases in melanoma patients with positive sentinel node biopsy, we carried out a retrospective study which included a total of 80 patients. MATERIAL AND METHODS: 80 patients with cutaneous malignant melanoma and subclinical lymph node metastases diagnosed by sentinel node biopsy (SNB) were submitted to 18F-fluoro-2-deoxy-D-glucose (FDG) whole-body PET-scanning within 100 days after SNB and wide local excision (WLE). Before FDG-PET scanning, patients were screened conventionally and found to be without evidence of further dissemination. The average follow-up was 30 months (range 7-81 months). RESULTS: 13 patients out of totally 80 patients had a suspicious FDG-PET scan. 4 of these patients (5%) were found true positive by verifying examinations. 67 patients had a negative FDG-PET scan - 4 of these patients developed a clinical recurrence within a period of 6 months after SNB (false negative). This resulted in a sensitivity of 50% and a specificity of 31%. CONCLUSION: We conclude that FDG-PET scanning in connection with SNB cannot be recommended as a routine investigation for patients with malignant melanoma and positive SNB.

Malignant melanoma in association with or mimicking blue naevus.

Malignant blue naevus is a rare but highly aggressive form of cutaneous malignant melanoma, which spreads often and early to the regional lymph nodes, liver, lungs, and other organs. We report three cases, review published reports, and recommend treatment.

[Prognosis after sentinel node biopsy in malignant melanoma]. / Prognosen efter sentinel node-biopsi ved malignt melanom.

INTRODUCTION: Sentinel node biopsy (SNB) is used in patients with cutaneous malignant melanoma (MM) to detect subclinical spread to the regional lymph nodes, after which a radical lymph node dissection can be performed. Since 2001, the Department of Plastic Surgery, Roskilde Amts Sygehus, has used SNB routinely in patients with cutaneous MM who have a statistical risk of at least 10% of harbouring subclinical lymph node metastasis. MATERIALS AND METHODS: In the four-year period from 2001 to 2004, 248 consecutive patients with primary MM underwent SNB at the time of radical surgery for their MM. If metastatic spread was found in the removed sentinel node, a radical lymph node dissection was performed shortly afterward. All patients were followed up after their operation in the department's outpatient clinic. RESULTS: Regional lymph node metastatic spread was found by SNB in 32% of the patients. At radical lymph node dissection, further metastatic lymph nodes were found in 24% of the dissected cases. The median follow-up time was 21 months (range 1-51 months). 7% of SN-negative cases developed recurrence during follow-up, in contrast to 23% of the SN-positive cases. The median time to recurrence was 14 months. The two-year and four-year disease-free survival rates were 93% and 85% in the SN-negative group and 73% and 55% in the SN-positive group, respectively. Risk factors for recurrence were: extracapsular SN growth, more than one metastatic SN and further lymph node metastases being found by formal node dissection. 18% of the SN-positive patients died during the follow-up period, in contrast to 3% of the SN-negative cases. The MM-specific two-year and four-year survival rates were 84% and 64% in the SN-positive group and 99% and 97% in the SN-negative group, respectively. CONCLUSION: Sentinel node biopsy is a procedure that detects MM patients who have a very high risk of recurrence and death by MM within a few years after primary treatment. SNB status is a very strong prognostic factor, and SN-positive cases should be followed carefully.

Routine use of FDG-PET scans in melanoma patients with positive sentinel node biopsy.

PURPOSE: Positron emission tomography (PET) scanning is an efficient and well-known diagnostic tool in various malignant disorders. However, the utility of PET as a clinical routine screening procedure for the detection of subclinical metastases in stage III melanoma patients has not yet been established. METHODS: Thirty-three patients with cutaneous malignant melanoma and subclinical lymph node metastases diagnosed by sentinel node biopsy (SNB) were submitted to( 18)F-fluoro-2-deoxy-D: -glucose (FDG) whole-body PET scanning within 100 days after SNB and wide local excision. Before PET scanning, patients were screened conventionally and found to be without evidence of further dissemination. Positive PET scan findings were evaluated by computed tomography scanning, magnetic resonance imaging and ultrasonography. Biopsy was performed whenever possible. The median follow-up was 15 months (range 6-39 months). RESULTS: Nine patients (27%) had a positive PET scan performed after SNB and WLE. On verification, four cases (12%) were found to be true positive for melanoma metastasis and were thus upgraded from stage III to stage IV. Furthermore, one patient (3%) had another primary malignancy (prostate carcinoma), and two (6%) were found to have non-malignant lesions. Two PET-positive patients (6%) refused further investigations. In one case (3%) the PET scan was false negative. Twenty-three (69%) PET scans were true negative. CONCLUSION: In a number of stage III melanoma patients with positive SNB, postoperative whole-body FDG-PET scanning revealed further melanoma dissemination not found by conventional screening methods and thus identified these cases as stage IV. Relevant therapy can accordingly be instituted earlier on the basis of FDG-PET scanning.

Sentinel node biopsy in cutaneous melanoma.

Status of the regional lymph nodes is a strong prognostic factor in patients with cutaneous malignant melanoma (CMM) and can be assessed by sentinel lymph node biopsy (SLNB). We present our technique of preoperative lymphatic mapping and intraoperative vital dye and handheld gamma probe. Our results and three years follow-up of its routine use in 198 patients with verified primary CMM are presented. Median follow-up time was 24 months (range 1-47). Metastatic regional lymph node disease was found by SLNB in 61 patients (31%) and additional metastatic nodes were found by formal node dissection in 30% of these cases. Complications were relatively mild but included one case of lymphoedema in a node negative patient. By follow-up, 13% had developed a recurrence including 26% of node positive patients and 8% of node negative patients. Mortality was also substantially higher in node positive cases with 18% dying in the follow-up period and 3% in the node negative group. The SLNB procedure was associated with a false negative rate of 8%. Using the presented technique, we found that SLNB was a useful procedure for staging patients with CMM and for selecting patients for more extensive metastatic screening and inclusion in trials of adjuvant treatments.